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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565800867
Report Date: 01/06/2026
Date Signed: 01/06/2026 04:13:39 PM

Document Has Been Signed on 01/06/2026 04:13 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME:ARC-HERITAGE VALLEYFACILITY NUMBER:
565800867
ADMINISTRATOR/
DIRECTOR:		SONIA SALINASFACILITY TYPE:
775
ADDRESS:116 NORTH 10TH STREETTELEPHONE:
(805) 933-9029
CITY:SANTA PAULASTATE: CAZIP CODE:
93060
CAPACITY: 90CENSUS: 33DATE:
01/06/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:45 AM
MET WITH:Kathleen “Katie” GomezTIME VISIT/
INSPECTION COMPLETED:
04:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) Esther Cortez arrived at the Adult Day Program (ADP) unannounced to conduct a required annual visit at 09:45 a.m. The LPA met with Administrator Kathleen “Katie” Gomez and explained the reason for the visit. The program currently operates from 8:00 a.m. to 3:00 p.m. The day program was staffed with 1:3 staff to consumer ratios.

Starting at 10:15 a.m., the LPA and the Administrator toured the physical plant to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. The smoke alarms and carbon monoxide detectors were tested throughout the tour and were operational. Cleaning supplies are stored in a locked area.
Common Activity Space: Furnishings were observed to be in good condition. The facility has two large activity spaces, a dining room, and a craft room. The LPA observed the required postings throughout the facility as well as the monthly activity schedule. The program site appeared to be clean, safe, sanitary, and in good repair at this time. The LPA observed fire extinguishers throughout the facility, which were last serviced 06/17/2025.
Activities: Activities are both designed for individual and as a group. Activity supplies were observed in the large activity room.
Restrooms: The three restrooms were observed to be clean and sanitary with a hand soap and paper towels. However, the men's restroom had a malodorous odor. The hot water temperature in the three restrooms were tested at 10:37 a.m., 10:41 a.m. and 10:45 a.m. and they measured at 104.5, 105.4, and 106.5 degrees Fahrenheit. Upon observation water temperature was adjusted in one of the restrooms. Report will continue on LIC809-C, 2nd page.
NAME OF LICENSING PROGRAM MANAGER: Kasandra Lopez
NAME OF LICENSING PROGRAM ANALYST: Esther Cortez
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 01/06/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/06/2026
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: ARC-HERITAGE VALLEY
FACILITY NUMBER: 565800867
VISIT DATE: 01/06/2026
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Food Service: The kitchen area was clean and locked. Consumers bring their lunch and snacks. The facility has emergency food supplies and snacks available for consumers.

Changing Room/Medication Room: The changing room had a supply of hygiene products, a bed with protective paper that is changed between clients and a hoyer lift if needed. This room is used as an isolation room if necessary, and is also where the medications are stored. The room is always locked.

Medication Audit: A medication audit for three (3) clients was initiated and the


following was observed. The medications were stored in a locked cabinet inside a locked office and
inaccessible to the clients. All medications were documented on the centrally stored medication and destruction log (CSMDR), however one of the clients (C1) medication's quantity was not documented on the CSMDR and C2 had a medication documented as taken in error.

Record Review: A review of facility files was initiated. The LPA observed documentation of Infection Control, Disaster prevention, Insurance liability and last fire drill (conducted on 11/21/25. The LPA obtained Client Roster, and Staff Roster. The LPA reviewed five (5) of thirty-three (33) client files and five (5) of nineteen (19) staff files. All resident and staff documents reviewed appeared complete and current.

Interviews: During today's visit, the LPA interviewed three (3) staff and four (4) consumers. No immediate concerns voiced at this time.

Pursuant to Title 22 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D). Exit interview conducted and copy of the report and appeal rights provided to Administrator.

NAME OF LICENSING PROGRAM MANAGER: Kasandra Lopez
NAME OF LICENSING PROGRAM ANALYST: Esther Cortez
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 01/06/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/06/2026
LIC809 (FAS) - (06/04)
Page: 3 of 6
Document Has Been Signed on 01/06/2026 04:13 PM - It Cannot Be Edited


Created By: Esther Cortez On 01/06/2026 at 03:55 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: ARC-HERITAGE VALLEY
FACILITY NUMBER: 565800867

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/06/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
82075(l)(7)(C)
82075 Health-Related Services (l) The following requirements shall apply to medications which are centrally stored:(7)The licensee shall ensure the maintenance, for each client, of a record of centrally stored prescription medications which is retained for at least one year and includes the following:(C) The drug name, strength, and quantity.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in C1's medication that did not have the quantity documented which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/16/2026
Plan of Correction
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The administrator shall ensure medication records have required information and staff receives training regarding regulation 82075 and medication records and submit proof of training to CCLD by 01/16/2026
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Kasandra Lopez
NAME OF LICENSING PROGRAM MANAGER:
Esther Cortez
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 01/06/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/06/2026


LIC809 (FAS) - (06/04)
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